COMPLIANCE AUDITOR
Position Summary
Performs complex professional internal auditing. Work involves compliance audit projects for Covenant Health entities as they relate to charging, coding, documentation and billing compliance. Also provides consulting services to the organization’s management and staff and may participate in requested investigations.
Maintains all organizational and professional ethical standards. Works independently under limited supervision. Reports to the Compliance Audit Manager.
Identifies and evaluates company risk areas and provides auditing procedures related to documentation coding and billing, including reviewing and analyzing findings.
Reviews and studies all information published by the federal government, fraud alerts, legal advisory opinions, and other publications related to coding, billing and reimbursement compliance, staying abreast of current regulations.
Performs research and analysis of charges, CPT coding, modifiers and billing processes to ensure compliance with Medicare, Medicaid guidelines and other insurance payor guidelines.
Collaborates with appropriate parties to complete over or under payments of claim errors identified during audits in accordance with Audit Policy.
Communicates or assists in communicating the results of audit project via written reports and/or oral presentations to physicians, clinical management, and presents as needed to related committees.
Documents all audit activities in a designated location; reports statistics and identified problems as directed by the Audit Workflow Process and Policy.
Affords assistance with special projects as requested.
Works in conjunction with health information management, patient accounting, information systems and other personnel to assist with implementation of solutions to mitigate risk.
Reviews and evaluates ongoing activities involved in the baseline and periodic compliance audits and compliance programs as deemed appropriate by manager.
Advocates, educates and acts as clinical/billing liaison between system-wide facility leaders, department managers and billing staff as designated by manager in relation to audit findings and process improvement initiatives.
Works independently and demonstrates the ability to successfully locate, interpret and apply regulations with which they may be otherwise unfamiliar, and recognizes situations which necessitate supervision and guidance from leadership.
Maintains lines of communication with Facilities/Clinics in an ongoing effort to improve the overall quality of customer service.
Motivates coworkers and promotes a team effort in accomplishing goals and deadlines with accuracy, dependability and professionalism.
Fulfills all other duties as assigned.
Minimum Education
None specified; however, must be sufficient to meet the standards for achievement of the below indicated license and/or certification as required by the issuing authority.
Minimum Experience
Three (3) to five (5) years’ experience in health care.
Good Working Knowledge
Of healthcare billing, Medicare/Medicaid billing guidelines, and other Third-Party Payor rules and regulations.
Experience in Problem Solving and Analytical Reviews
Necessary.
Knowledge of Use of PC's, Windows, Excel and Word Processing
Necessary.
Good Public Relations Skills
Necessary.
Licensure Requirement
Must have and maintain RHIT, RHIA, CCS, CPC (or equivalent certification), or current TN RN License with equivalent coding experience.